Monday, October 18, 2010

Chilean Miners, Informed Consent, and Medical Ethics

I've never met Chris MacDonald, but I admire his superb Business Ethics Blog. Chris teaches philosophy and business ethics at Saint Mary's University in Halifax, Canada.

This post is triggered by what Chris wrote yesterday about the recently rescued Chilean miners, but a paragraph from his post today explains what I like so much about his way of approaching ethics. I highlighted the key sentence:

A bit of economics can go a long ways in helping understand a range of issues in business ethics. I’m not an economist myself, but I’ve read a fair bit of economics here & there. And I want to read more. In order to arrive at sound ethical conclusions, you need more than just ethical beliefs: you need some understanding of how the world works. For many issues in business ethics, economics provides relevant facts.

Chris hits the nail on the head. In medical ethics, as in business ethics, to "arrive at sound ethical conclusions" requires ability to reason well and even a bit of theory, but also practical knowledge "of how the world works."

Chris discusses two fascinating questions about the miners. First, what law are they under? He cites a law review paper from 1949 that imagines trapped miners who agree to shoot dice to see which one of them will be killed and eaten by the others. Without cannibalism, all will starve to death. When rescued, the survivors are tried for murder. Four judges find them guilty. The fifth acquits them. He argues that while trapped, they formed a mini-society, cut off from the system of government above them, and appropriately created their own form of civil society. Happily, no situation of "earthly crime" occurred in Chile, but the question of how it would have been handled after rescue is not simple.

The second question is relevant for medical ethics. While trapped, the miners drew up a contract agreeing to share equally any profits from telling their story (see here). But Chris asks - in the situation of entrapment, was true informed consent possible? He speculates that the largely positive force of strong group pressure for cooperation might be seen as creating "undue influence" and "duress."

Many years ago, my primary care physician referred me for a cardiac stress test. I arrived at the site, was ushered to the treadmill, and given several pages to read to get my "consent." The technician was standing by, in effect twiddling his thumbs. It wasn't a situation for leisurely perusal and reflection on risks and benefits! I knew enough about the test so that I could sign without reading the mini-tome, but in a minor way, the setting embodied the kind of "undue influence" and "duress" that Chris imagines in the Chilean mine.

In medical ethics class we teach all about the difference between explanation, persuasion, manipulation and coercion in seeking informed consent. Unfortunately, those lessons are often undone when students get to their clinical rotations and are sent off with a clipboard to "consent the patient" before a procedure is done.

Another factor, closer to my own field of psychiatry, involves all the discussion of the miners' supposed need for psychological treatment. The teams working with them while they were trapped were very sophisticated in their psychological thinking, as by not sending down games likely to provoke competition. 2300 feet underground it would be too easy for disputes to get out of hand.

The Chilean government will make six months of counseling available to the men. But some columnists have written that the men will surely suffer psychological disorders on their return. In their view, counseling is inevitably required. In actuality, some probably will need that kind of help, but others probably wont. In our mental health oriented, sometimes psychobabble dominated, culture, we can do inadvertent harm by our assumptions about how the psyche "must" work.

Years ago I did that myself while supervising a psychiatric resident in treating a mildly retarded man who had been incarcerated in a state facility as a teen for exposing himself in public. He had spent the next 50 years in the facility until the deinstitutionalization movement led to his being transferred to a community residence. He seemed happy. I said to the resident - "that can't be all there is to it. After all, he's lost his home of 50 years."

The resident probed and probed. We concluded that I was wrong. Remarkably, the man expressed no resentment for his incarceration. He was a simple soul, and took pure pleasure in being able to go to the neighborhood store when he wanted. In my supervision I'd imposed an assumption on him rather than letting him speak for himself.

With veterans returning from Iraq and Afghanistan, we're doing the right thing by emphasizing that "warriors" who are depressed are strong, not weak, when they ask for help. But in my practice I saw many people who were so persuaded that there was only one way to experience grief that if they didn't cry their unshed tears would create the equivalent of a poisonous toxin inside. Societal receptiveness to sadness and tears turned into a command for them.

In medicine, a core component of the "understanding of how the world works" required for ethical practice comes from listening to our patients without imposing stereotypes and preconceptions.